Psychiatric Hospitals With Safety Violations Still Get Accreditation
by Stephanie Armour Wall Street Journal December 26, 2018
More than 100 psychiatric hospitals have remained fully accredited by the nation’s major hospital watchdog despite serious safety violations that include lapses linked to the death, abuse or sexual assault of patients, a database investigation by The Wall Street Journal has found.
The Joint Commission, an Oakbrook Terrace, Ill., nonprofit that evaluates most of the nation’s hospitals, revoked or denied full accreditation to fewer than 1% of psychiatric hospitals it oversaw in fiscal 2014 and 2015, the latest date for which detailed federal data is available. State inspectors found about 16% of those hospitals each year, or about 140 institutions total, operated with such severe safety violations they could put federal funding at risk.
Troubled hospitals have promoted their continued accreditation to attract new patients, in some cases even after the federal government terminated their Medicare funding due to recurring safety risks.
Psychiatric hospitals kept their accreditation after patients said they were raped or assaulted; died by suicide; or slept on chairs due to crowding, among other incidents, according to a review of hundreds of pages of state inspection reports.
The Joint Commission, a private body authorized by the government to review hospital performance, has long held an accrediting monopoly. It inspects almost 90% of the nation’s psychiatric hospitals, and the federal government relies on its findings. The commission determines whether hospitals comply with federal safety-related regulations. Hospitals determined by the commission to be in compliance get accreditation.
A lot of money is at stake: Medicare payments to inpatient psychiatric facilities reached $4.5 billion in 2017, growing an average of 1% each year since 2006, according to federal data.
The Joint Commission is currently the only accrediting organization with a federally approved psychiatric-hospital accreditation program for Medicare. It also accredits nearly 1,900 behavioral-health organizations such as group homes and addiction-treatment centers.
The Journal previously reported that the Joint Commission continued to accredit a variety of hospitals despite safety violations. In the case of inpatient psychiatric hospitals, the patients and staff are especially vulnerable, because so many of the patients are suicidal and cared for in the absence of family members who often act as patient advocates.
Psychiatric centers, like other hospitals, pay the Joint Commission for its inspections, and some hire consultants from a commission subsidiary to help them pass those reviews, which many ethics experts consider a conflict of interest.
Commission officials said that their surveys of hospitals shouldn’t be considered regulatory inspections and that they work collaboratively with psychiatric hospitals to help them improve.
“It is important to acknowledge an uncomfortable reality: There are no perfect hospitals anywhere in the world,” the Joint Commission said.
Some mental-health experts say the current system features the wrong incentives.
“Accrediting bodies can’t make the standards too high or no one will ever pay for it,” said Benjamin Miller, chief strategy officer at Well Being Trust, an advocacy group on mental health and wellness. “Accreditors are all in the business to make money.”
The Journal found 141 psychiatric hospitals, out of roughly 490 across the country, that were accredited by the Joint Commission and cited by state officials from fiscal 2014 and 2015 for serious violations.
For most of the 141, those violations weren’t the first; they had an average of eight serious violations in the years going back to 2011, according to state inspection records and Hospitalinspections.org. Some had dozens of previous violations.
“I am very concerned about the data. It’s showing us there is a disparity between their surveys and ours,” said Seema Verma, administrator of the Centers for Medicare and Medicaid Services. “You want to be sure accreditation means something.”
CMS checks accreditors’ work using a formula known as a disparity rate to gauge how often safety issues were overlooked. Its data shows the commission’s reviews of psychiatric hospitals had a 57% rate, which officials described as concerning and the highest of all types of hospitals.
Commission officials say they work closely with institutions to fix problems. But the psychiatric hospitals that kept their full accreditation after an incident had an average of nine major violations since then, with some having more than 30.
Those later violations include sexual assault, the alleged rape of a teenage patient, the administration of psychotropic medication without consent and failure to give insulin to diabetic patients, according to state inspection records. State inspectors said one patient sustained a skull fracture because the hospital failed to implement safety measures. Another hospital failed to adequately investigate when a staff member used a phone to take pictures of a patient’s breasts, inspectors said.
In 2016, Austin Skidmore resided at Laurel Heights Hospital, a psychiatric residential facility for autistic youth in Atlanta owned by Universal Health Services Inc. During an episode when the 19-year-old became agitated, according to a lawsuit filed by his family, an employee held him down and another held his legs.
Several minutes later, Mr. Skidmore’s face turned blue, and he choked on his own vomit in a death that the medical examiner classified as a homicide.
State inspectors in December issued a report saying that “the facility used a manual hold in a manner that would potentially impair the patient’s ability to breathe resulting in the death of the patient.”
Laurel Heights officials said in court filings their actions weren’t at fault in Mr. Skidmore’s death. “This was an unfortunate and isolated incident and is not representative of the compassionate care that our staff and clinicians provide,” Jane Crawford, a spokeswoman for UHS, said in an email.
The facility has kept its accreditation. “We are aware that Laurel Heights has remained fully accredited since Austin’s death, and are concerned,” said Austin’s father, Jack Skidmore. “Austin was a very special child, and we miss our son dearly.”
Rep. Greg Walden (R., Ore.), who chairs the House Energy and Commerce Committee, which oversees health issues, said the panel began an investigation into the accreditation process after the Journal’s initial story on hospital accreditation in September 2017.
“These findings are of great concern and underscore the need to critically evaluate the performance of accrediting organizations in all segments of the health-care sector,” Mr. Walden said of the new data findings on psychiatric hospitals.
When safety problems arise, the federal agency can terminate Medicare funding, but that is a move of last resort, since medical centers cut off from such funding are often forced to close.
Some industry leaders expressed disbelief that a hospital that was terminated from Medicare could keep its accreditation.
“If they’re terminated, they wouldn’t be accredited. I don’t see that. I’m not aware of that happening,” said Mark Covall, president and chief executive of the National Association for Behavioral Healthcare, which represents more than 1,000 behavioral facilities.
But that is what happened at Timberlawn Behavioral Health System, a psychiatric hospital in Dallas, which was cut off from Medicare in August 2015 for repeated and serious violations. It kept its accreditation and displayed the accompanying Joint Commission “Gold Seal of Approval” on its website to recruit potential patients. The hospital is now closed.
Timberlawn had received nearly $20 million in Medicare funding since 2014.
Eastern State Hospital, a psychiatric hospital in Williamsburg, Va., also kept its full Joint Commission accreditation after it was terminated in April 2016 from Medicare, which funded over $1 million in treatment from 2014 to 2016.
The accreditation industry is facing heightened scrutiny following the Journal’s initial report. The Trump administration said last week it was weighing whether to continue approving accrediting organizations that also have consulting arms, which would include the Joint Commission. CMS, a division of the Department of Health and Human Services, has announced increased oversight. Officials unveiled a pilot project to change how they evaluate accrediting organizations, and said they would provide the public with new information about the performance of accreditors and hospitals.
The Energy and Commerce Committee launched an investigation in March into accrediting organizations. And Sen. Chuck Grassley (R., Iowa) is working with CMS staff to determine what statutory changes are needed to make accreditors’ confidential inspection reports public.
The Joint Commission said most hospitals come into compliance once deficiencies are pointed out. “The goal of the private accreditation system is to identify deficiencies in care and have the hospitals correct those deficiencies—it is not to find as many deficiencies as possible to justify removing accreditation from those organizations,” the commission said.
About three-fourths of the psychiatric hospitals found with violations in 2014 or 2016 went on to have later violations, according to an analysis of the federal data.
CMS officials, who oversee the commission and grant it authority to inspect hospitals, have been concerned for years about the accreditation of psychiatric hospitals.
In December 2015, CMS cited “serious issues” regarding the commission’s performance. It later put its psychiatric-accreditation program under probation, which ended in December 2016. But CMS ultimately backed the program, saying it would closely monitor the commission’s work.
—Paul Overberg contributed to this article.